Surgical Procedures: Surgery and Staging for Rectal Cancer
What is staging and how is it performed?
When there are malignant (cancerous) cells in the rectum, this is referred to as rectal cancer. Measuring 6-8 inches, the rectum and anal canal make up the end of the large intestine fully ending at the anus where stool is passed from the body.
Most commonly, rectal cancers originate in adenomatous polyps of the rectum, a precancerous condition which at times can develop into a cancer and potentially invade the rectal wall. Other less common types of rectal cancers include:
- Carcinoid tumors
- Gastrointestinal stromal tumors (GISTs)
Once a diagnosis of rectal cancer has been made or if there is suspicion that the disease is present, your healthcare provider will typically obtain additional testing to determine the stage of cancer which may include:
Physical Exam: This is a general physical exam, as well as, an evaluation of your medical history and symptoms. This exam will also include a digital rectal exam to evaluate the rectum for any abnormalities; in women, a vaginal exam may also be completed.
Radiologic Imaging: Imaging such as a chest X-Ray, CAT scan (CT scan), positron emission tomography scan (PET scan), magnetic resonance imaging (MRI) and/or endoscopic ultrasound (EUS) may be used to further evaluate the extent of your cancer.
Procedures: Specialized procedures may include:
- Fecal Occult Blood Testing: Also referred to as guaiac-based fecal occult blood test (gFOBT) and fecal immunochemical test (FIT), these tests will evaluate for blood in the stool.
- Stool DNA testing: This test evaluates for abnormal DNA found within the stool.
- Blood testing: Your healthcare team may obtain blood samples which may indicate the presence of cancer such as a carcinoembryonic antigen (CEA) level, which may be evaluated and followed over time.
- Radiologic Imaging: Imaging such as a chest X-ray, CAT scan (CT scan), virtual colonscopy, magnetic resonance imaging (MRI), positron emission tomography scan (PET scan) and/or endorectal/transrectal ultrasound may be used to further evaluate the extent of your cancer.
Procedures: Specialized procedures may include:
- Colonoscopy: During a colonoscopy, a colonoscope (lighted, flexible tube) is inserted into the rectum, reaching the whole colon for evaluation of any abnormalities. At this time, biopsies may be obtained for evaluation in the lab.
- Sigmoidoscopy: During a sigmoidoscopy, a sigmoidoscope (lighted, flexible tube) is inserted into the rectum and the lower portion of the colon called the sigmoid colon to evaluate for any abnormalities. At this time, biopsies may be obtained for evaluation in the lab.
- Double-contrast barium enema: Also known as a lower GI series, this test uses the liquid enema contrast barium, to evaluate under X-ray abnormalities in the lower gastrointestinal tract which includes the colon and the rectum.
- Biopsy: To evaluate for cancer at the cellular level, biopsies may be obtained to send to the lab to evaluate for cancer and possibly a genetic mutation called hereditary nonpolyposis colorectal cancer.
Rectal cancer spreads to other parts of the body through the tissue, lymph and blood systems. Cancer stage determines how extensive the cancer, how far it has spread and what treatment course will be recommended. Rectal cancer is described as stages 0 through stage IV disease.
Often times, it may be recommended that those with rectal cancer undergo surgery.
Surgical Procedures for Rectal Cancer
There are several common surgical procedures used to treat rectal cancer, depending on your particular stage and situation, including:
- Polypectomy/Local excision: During this procedure, a colonoscope (as in the colonoscopy) is used to remove a polyp or abnormal area of cancer. During a polypectomy, only the present polyp is removed, whereas during a local excision (also known as an endoscopic mucosal resection), some of the tissue on the rectal wall is also removed.
- Local transanal resection: Otherwise referred to as a full thickness resection, this procedure involves removing the cancer within the rectum, as well as, surrounding healthy tissue through the anus. This procedure may additionally require that lymph nodes and the tissue lying between the rectum and abdominal wall be removed simultaneously. In some cases, surgeon may use a magnifying scope to perform a transanal endoscopic microsurgery (TEM).
- Low anterior resection: Also referred to as an LAR, a low anterior resection involves removing the affected tissue in the upper portion of the rectum. Additionally, some healthy tissue and lymph nodes are removed for evaluation and the colon and rectum are surgically re-connected, however, at times a temporary ileostomy will be recommended to allow for adequate healing.
- Abdominoperineal resection (APR): During this procedure, the anus, anal sphincter and surrounding tissue is removed, requiring a permanent colostomy.
- Proctectomy with colo-anal anastomosis: During this procedure, the entire rectum is removed, subsequently connecting the colon directly to the anus. At times, surgeons will create a pseudo rectum using a portion of the colon which will then store fecal matter for elimination. In some cases, there is a need for a temporary ileostomy.
- Radiofrequency ablation: During this procedure, electrodes kill cancer through a probe inserted through the skin or an abdominal incision.
- Cryosurgery: During cryosurgery, abnormal cells are frozen and killed.
- Pelvic exenteration: This procedure entails removing the rectum, bladder, prostate in men or uterus in women. This surgery will require a colostomy and at times a urostomy for voiding stool and urine respectively.
- Diverting colostomy: During a diverting colostomy, a rectal blockage can be relieved by placing a diverting colostomy (ostomy placed above the tumor in the GI tract).
- Surgery for metastatic disease: At times, rectal cancer may spread to other parts of the body, such as the lungs or liver, and it may be recommended that these areas be removed. These procedures are dependent on several factors which your healthcare provider will discuss with you.
Note: Depending on your personal situation, your surgeon may consider techniques such as minimally invasive surgery with laparoscopy or robotic surgery, as well as nerve-preserving surgery which aims to preserve urinary and sexual function.
What are the risks associated with rectal cancer surgery?
As with any surgical procedure, there are risks and side effects associated with undergoing rectal cancer surgery. Risks and side effects associated with rectal cancer surgery may include:
- Reaction to anesthesia
- Blood clots
- Anastomotic leak (leakage from the joined colon or anastomosis site)
- Incisional separation
- Development of adhesions/scar tissue
- Bowel obstruction
- Need for colostomy or ileostomy which can affect body image
- Potential erectile dysfunction, orgasm abnormalities and impaired fertility in men
- Potential painful intercourse and loss of ability to carry a child in women which is procedure dependent
What is recovery like?
Recovery from rectal cancer surgery will depend on the extent of the procedure performed. A hospital stay is typically required.
You will be instructed on how to care for your surgical incisions and/or ostomy and will be given any other instructions prior to leaving the hospital.
Your medical team will discuss with you the medications you will be taking, such as those for pain, blood clot, infection, constipation prevention and/or other conditions.
Your healthcare provider will discuss your particular activity restrictions depending on the surgery you have had and will give you specific parameters of when to call your healthcare team.
What will I need at home?
- Thermometer to check for infection.
- Loose clothes and underwear.
- Incision and/or ostomy care items, often times supplied by the hospital/physician office.
How can I care for myself?
Depending on the extent of your surgery, you may need a family member or friend to help you with your daily tasks until you are feeling better and your medical team gives you the go ahead to resume normal activity.
Be sure to take your medications as directed to prevent pain, infection or other conditions and call your medical team with any concerning symptoms.
If constipation is present, speak with your healthcare team about recommendations they have to offer relief.
Deep breathing and relaxation are important to help with pain, keep lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to perform deep breathing and relaxation exercises several times a day in the first week, or whenever you notice you are particularly tense.
- A simple exercise to do on your own: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.
This hand-out provides general information only. Please be sure to discuss the specifics of your surgical plan and recovery with your surgeon.
National Cancer Institute. Rectal Cancer Treatment (PDQ®)–Patient Version. 2018. Found at: http://www.cancer.gov/types/colorectal/patient/rectal-treatment-pdq
American Cancer Society. What is Colorectal Cancer? 2018. Found at: http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-what-is-colorectal-cancer
American Cancer Society. Surgery for Rectal Cancer. 2018. Found at: http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-treating-rectal-surgery
MSKCC. Surgery for Rectal Cancer. Found at: https://www.mskcc.org/cancer-care/types/rectal/treatment/surgery